Provider Demographics
NPI:1124130273
Name:MEDINA, EUGENE
Entity type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3390 MT DIABLO BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549
Mailing Address - Country:US
Mailing Address - Phone:925-284-6150
Mailing Address - Fax:925-284-6155
Practice Address - Street 1:3390 MT DIABLO BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549
Practice Address - Country:US
Practice Address - Phone:925-284-6150
Practice Address - Fax:925-284-6155
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ17431ZMedicare ID - Type Unspecified